ADMISSION CONFERENCE
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Transcript of ADMISSION CONFERENCE
Clerk Hannah Lea David
December 10, 2010
Date of birth: December 9, 2010 Time of birth: 3:14 am
• Born to a 27 y/o G1P0 housewife, married to a 32y/o OFW
• Regular prenatal check-up since 2 mos. AOG ▫ Holy Clinic Navotas– 2 mos. AOG▫ Fabella Hospital (3 visits)- 7 mos AOG▫ USTH- 8 mos AOG▫ Total of >10 visits
• Regular intake of multivitamins and ferrous sulfate
• Denies exposure to viral exanthems, radiation
• Denies intake of illicit / regulated / prohibited / abortifacient drugs
• Non smoker, denies alcohol intake during pregnancy
Labs & Ancillaries:Hep B screening: HBsAg reactiveRPR: Non reactiveOGCT: normalCBC, U/A: NormalLast UTZ done 11/12: Single, live,
intrauterine pregnancy about 34 weeks & 4 days, BPS 8/8, EFW 2586+/- 387g
LMP: March 21, 2010, AOG: 37-38weeks (+) Mixed vaginosis- Metronidazole
suppository x 7 days at 8 months AOG (+) Hepatitis B diagnosed 2003 No history of hypertension, DM, thyroid
disorder, preterm labor
No hx of hypertension, DM, Cardiovascular diseases, thyroid disorder, PTB, hepatitis
10:30 AM BP 140/100 130/100 LAT: BFHR 150-160 bpm, good variability, (+)
accelerations (-) decelerations 12 MN- BP 120/80
BFHR 140-150 bpm Good variability, (+) acceleartions (-) decelerations
thinly stained amniotic fluid 2:30 AM- BP 120/80
BFHR 140-150 bpm, good variability with accelerations, no deceleration.
Live, term, singleton, male via NSD BW 2.98 kg, BL 50 cm, HC 32 cm, CC
30.5 AC 27cm APGAR Score 8, 9 MT 38-39 weeks AOG AGA
• VS: HR 154 bpm, RR 61, T: 36.8oC• BW 2.98 kg, BL 50 cm, HC 32 cm, CC 30.5
cm, AC 27cm• Active, good cry, good muscle tone,
acrocyanotic• (+) Mongolian spots• (+) caput succedaneum, (+) molding, no
cephalhematoma, patent, flat anterior fontanel
• (+) ROR, no eye discharge, no anomalies, normal set ears, no preauricular sinus, patent nares, no cleft lip and cleft palate
• Clavicle intact
• Symmetric chest expansion, no retractions, clear and equal breath sounds
• Adynamic precordium, rhythm regular, S1 and S2 normal, no murmurs
• Globular abdomen, umbillicus with 2 arteries and 1 vein, soft, no organomegaly, no masses
• Genitalia: bilaterally descended testes, good rugae
• Femoral pulses full and equal• (-) Barlow, (-) Ortholani• Spine normal curvature, no sacral dimpling, no
tufts of hair • no edema, no cyanosis• (+) moro, grasp, rooting, plantar, sucking,
swallowing reflexes
• Patient was dried and stimulated to cry• Cord clamping was done• Skin to skin contact• Latching done• Newborn care:
▫ Erythromycin eye ointment 1cm strip OU▫ Cord care with 70% ethanol▫ Vitamin K 1mg/IM▫ Hepatitis B vaccine, 0.5mL/IM on the
anterolateral thigh▫ Hepatitis B Ig 0.5 mL/IM
• Vital Signs monitored
• Bathing at 6th hour of life• Patient roomed in and exclusively
breastfed• For hearing screening on the 24th hour
of life• For newborn screening beyond 48th
hours of life
Total = 8
Total = 9
ASSESSMENT